Following completion of my oncology fellowship, I was excited to start my first faculty position as a neurosurgeon-scientist at the University of Arkansas. Given my interests in addressing cancer health disparities, I looked forward to building a neuro-oncology program in a poor rural state where I was the only fellowship-trained neurosurgical oncologist. I simultaneously started my independent translational research laboratory. I always believed that through research, I could affect many more lives than what was possible in my clinical practice. Exactly how to go about balancing this life was truly unknown to me. I had some defining moments that have helped me learn to navigate this difficult path.
In my first year of practice, I performed a complex skull base surgery during the same week of a grant submission. Unfortunately, my patient had a complication which a return to the OR. It was an extremely difficult week as I worried about the outcome of my patient who faced severe disability and death. I spent much of my time in the ICU talking to family and then, using a skill picked up in residency, intermittently forced myself to switch off those emotions and work on finishing a grant application. At the end of the week, by some miracle, the grant was submitted while I still agonized about my patient’s terrible postoperative course. In this circumstance, it was best to separate the two worlds between neurosurgeon and researcher; I was ultimately awarded the grant. However, it was truly a wakeup call in the complexities of balancing the clinical and research priorities, as clinical neurosurgery is unforgiving and unpredictable.
The second formative experience was a result of a conversation with one of my patient’s family members. My patient was a young woman with head and neck cancer with perineural invasion. Despite radiosurgery, the cancer spread to her brain and leptomeninges. She was the first patient in whom I used next-generation sequencing to try to identify a target. Her tumor (SMARCB1-deficient sinonasal carcinoma) was extremely rare with rhabdoid features. I was not able to find a targeted therapy for her but posthumously I called the family to get permission to publish her case report [1]. They agreed to have her report published but their questions haunted me. “Why didn’t this test help her when she was alive? What was the point?” While I apologized for my inability to help her, I promised to use the information to effect change while people were alive.
This question inspired me to critically evaluate how best to use next-generation sequencing results, as well as brain tumor biobanking [2]. As someone caring for cancer patients who are trying desperately to prolong their lives, the need for translational relevance was dire. Now about 2 years later, I have established a pipeline to combine omics data and ex vivo tumor modeling to find targets for patients. The first patient to receive treatment based on this paradigm had been clinically stable for months. They have gone through the fire, but that day we happily joked about plans for the future and sneaking champagne into clinic to celebrate their health. This patient represents a true marriage of my two worlds, neurosurgery and research; I am elated to fulfill the promise I made to that earlier patient’s family.
I am still learning how to balance these worlds and when to separate or combine them. I am truly blessed to get inspiration for my research directly from patients themselves. However, when people ask me about what it is like to be a clinician scientist, I immediately correct them and say “surgeon-scientist”. Maintenance of advanced operative skills as a surgeon is imperative to your practice and requires time and dedication. Inherently the “balancing” act is more difficult in surgical and procedural specialties. Interestingly, neurosurgery, in comparison to other surgical specialties, has had the most significant increase in the number of surgeons obtaining NIH funding as surgeon-PIs [3]. To me this is not entirely surprising, as I have been humbled by meeting many aspirational neurosurgeon-scientists who conduct transformative research to change lives for the better. I hope that I can become one of them; in the end, it remains a privilege to try to help patients in any way possible.
References
- Gomez-Acevedo, H.; Patterson, J.D.; Sardar, S.; Gokden, M.; Das, B.C.; Ussery, D.W.; Rodriguez, A. SMARC-B1 deficient sinonasal carcinoma metastasis to the brain with next generation sequencing data: A case report of perineural invasion progressing to leptomeningeal invasion. BMC Cancer 2019, 19.
- Darrigues, E.; Elberson, B.W.; De Loose, A.; Lee, M.P.; Green, E.; Benton, A.M.; Sink, L.G.; Scott, H.; Gokden, M.; Day, J.D.; et al. Brain Tumor Biobank Development for Precision Medicine: Role of the Neurosurgeon. Front. Oncol. 2021, 11.
- Langston, R.G.; Zhao, E.H.; Wong, K.H.; Rodriguez, A. Recent trends in NIH funding for top surgeon-scientists. Am. J. Surg. 2021, 222, 281–285.
